Mobilehome Tax Clearance Certificate Request
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2COUNTY OF RIVERSIDE TREASURER-TAX COLLECTOR
th
4080 LEMON STREET 4
FLOOR / P.O. BOX 12005
ATTN: MOBILEHOMES
RIVERSIDE, CA 92502
PHONE: 951-955-3900
MOBILEHOME TAX CLEARANCE CERTIFICATE REQUEST
Requested By:
_______________________________________
Date:
________________________
Mailing Address:
_______________________________________
Escrow #: ________________________
(REQUIRED)
_______________________________________
Phone #: ________________________
Escrow Officer:
_______________________________________
Email:
________________________
(IF APPLICABLE)
Please provide all of the requested information pertaining to the current registration. We cannot issue a clearance
without it. Complete this form and return it with a copy of the registration or title search.
ASSESSMENT NUMBER: _____________________________________________________________________________
CURRENT REGISTRATION INFORMATION:
License / Decal #: __________________________________
Vin / Serial #: __________________________________
Make:
__________________________________
Year:
__________________________________
REGISTERED OWNER’S NAME (As shown on current title with State):
Seller:
______________________________________________________________________________
Mailing Address:
______________________________________________________________________________
______________________________________________________________________________
Location of Home:
______________________________________________________________________________
______________________________________________________________________________
NEW OWNER’S NAME (How new title should read):
Buyer:
______________________________________________________________________________
Mailing Address:
______________________________________________________________________________
______________________________________________________________________________
Future Location:
______________________________________________________________________________
(IF BEING MOVED)
________________________________________
Date Moved: _____________________
TAXES DUE MUST BE MADE BY MONEY ORDER OR CASHIER’S CHECK. CASH PAYMENTS ARE ACCEPTED ONLY AT THE MAIN
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OFFICE LOCATED AT 4080 LEMON ST, 4
FL., RIVERSIDE, CA 92501. PLEASE BE ADVISED THAT PAYMENTS MADE BY
PERSONAL CHECK WILL RESULT IN A 30 DAY WAITING PERIOD BEFORE OUR OFFICE IS ABLE TO ISSUE THE TAX CLEARANCE
CERITIFICATE.
TREASURER-TAX COLLECTOR’S USE ONLY
TC REQUEST RECEIVED:
TAXES PAID
: CURRENT / ESTIMATE / ESCAPE(S)
(CIRCLE TAX PAID)
DATE RECEIVED: ____________ RECEIVED BY: ___________
PR. YR. / SUPPLEMENTAL / UNSECURED / MH ESC / DUP. REQ.
1
st
FL / 4
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FL / PALM DSRT / TEM / COUNTER / FAX / MAIL
DATE PAID: _______________ RECEIVED BY: ___________
REC’D BY MH DESK: ____________ RECEIVED BY: ________
AMOUNT PAID: _____________
CT #: ________________
FWD TO SATELITE OFFICE FOR PROCESSING: _____________
DOC #: ___________
GENERAL RECEIPT #: ___________
117-11A (05/2015)
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